NTSB says pilot error probably caused fatal Md. medevac crash

By Jenna Johnson and Mary Pat Flaherty
Washington Post Staff Writer
Wednesday, October 28, 2009

A Maryland State Police helicopter pilot made a questionable decision to fly on a foggy night last year. Air traffic controllers were inattentive, unhelpful and sloppy. Troopers tracking the medical rescue flight were complacent and slow to recognize that the helicopter was lost and ran a scattershot search.

That's what federal transportation safety investigators said Tuesday as they detailed extensive failures on Sept. 27, 2008, when Trooper 2 crashed in Prince George's County, killing four.

For decades the state-run program had been praised as "the gold standard" for emergency medical flights, said National Transportation Safety Board member Robert L. Sumwalt. But once federal investigators "peeled back the layers," they found systemic problems in the state-run program, he said. "The taxpayers of Maryland should be disappointed."

The board narrowed the probable cause of the crash to pilot error: He descended too quickly, trying to see through the fog , and flew straight into the ground. But the board also found shortcomings throughout the program.

Maj. A.J. McAndrew, commander of the state police aviation unit, said the program has improved training and safety. McAndrew described the pilot, Stephen Bunker, 59, as "very experienced" and said that although he values the board's comments, "we believe we are the gold standard." The program's last fatal crash was in 1986.

Trooper 2 was transporting two teenagers with low-level injuries from a car accident in Waldorf to Prince George's Hospital Center. They bypassed the hospital due to fog, aiming for Andrews Air Force Base, but crashed into Walker Mill Regional Park around midnight.

Killed were Bunker; state police paramedic Mickey Lippy, 34; volunteer medic Tonya Mallard, 38; and Ashley Younger, 17. The sole survivor was Jordan Wells of Waldorf, now 19, who has undergone more than 20 surgeries.

The board said Bunker did not properly assess the risk of taking the flight and, after the weather deteriorated, lacked the skill to safely land by relying on aircraft instruments. Ten months before the crash, the state police had scaled back such pilot training.

The "poor services" of federal air traffic controllers at three towers added to Bunker's workload as the flight went awry, the NTSB staff said. Controllers gave Bunker an hours-old weather report, did not vigilantly monitor the flight and could not give Bunker the extra help he requested in his final minutes, investigators said.

There was no evidence of mechanical failure or malfunction, the NTSB found. Trooper 2 did not have a system on board that would have warned Bunker several times that he was about to crash, a safety improvement the NTSB has aggressively promoted.

State police officials could have pinpointed the downed helicopter to within a few hundred feet using systems they had in place, but they did not know how to use them, the NTSB said. It took two hours to locate the wreckage and would have taken "several more hours" if two state police employees had not taken the initiative to focus the search, NTSB staff said. The pair found Wells screaming in the woods, covered with fuel.

The Maryland crash occurred during the deadliest year ever for medical helicopters with 28 deaths. A September crash in South Carolina killed three, the only fatal accident this year. In August, a Washington Post investigation found that working on medical helicopters is one of the riskiest jobs in America.

Wells said after Tuesday's hearing that while accidents occur, "with accidents come consequences." She suffered "the loss of my friend" and having "my life changed forever," physically and emotionally."

Younger's mother, Stephanie Younger, approached NTSB Chairman Deborah A. P. Hersman after the hearing, asking why many safety features are not mandated. Hersman explained that the board makes recommendations and that it is up to Congress or the Federal Aviation Administration to make rules.

Younger began to cry.

Hersman reached into her purse for a tissue and hugged Younger, saying, "I am so sorry."

© 2009 The Washington Post Company